There were few HIV infections as a consequence of early resumption of sexual activity after circumcision, an analysis of three major studies conducted in Africa has shown. However, investigators writing in the July 31st edition of AIDS caution that their data “do not preclude the possibility” that men who have sex in the first few weeks after circumcision have an increased risk of infection with HIV.
Three large studies in Africa (the Kisumu, Rakai and Orange Farm trials) showed that circumcised men had their risk of infection with HIV reduced by between 50 and 61% compared to uncircumcised men.
Concerns have been expressed, however, that the wounds and inflammation occasioned by circumcision could mean that men have an increased risk of infection with HIV should they resume sexual activity before full healing.
Investigators therefore conducted an analysis of the three circumcision studies to see if the resumption of sexual activity within 42 days of circumcision, or before complete wound healing, increased the risk of infection with HIV.
Men in the studies were counselled to avoid sexual intercourse for at least 30 days after circumcision, or until complete wound healing.
Only 4% of men in the Kisumu study and 5% of men in the Rakai study reported the resumption of sexual activity within 30 days of circumcision. However, early sexual intercourse was reported by over a fifth (23%) of men in the Orange Farm trial.
In all three studies, men who were married as well as men who reported higher numbers of sexual partners were more likely to report early sex.
Three months after circumcision, three of the 1266 Kisumu study participants had contracted HIV. None of these men had reported the early resumption of sex. Similarly, none of the men who reported sexual intercourse soon after circumcision in the Orange Farm study had seroconverted after three months.
At the six month follow-up visit, 0.4% of men in the Kisumu study who did not report early sex had become infected with HIV compared to 2% of individuals who did resume sexual activity early. Similarly, in the Rakai study a higher HIV prevalence was found amongst men who resumed sexual activity early compared to those who did not (2 vs 1%).
Statistical analysis showed that the early resumption of sexual activity increased the risk of infection at six months (odds ratio [OR] = 2.00; 95% CI 0.32-13.6), but this was not statistically significant. However, the investigators caution that the low numbers of HIV infections meant that there was “insufficient power to detect meaningful associations”.
In the Kisumu study, few men (16) resumed sexual activity before complete wound healing. One of these men (6%) became infected with HIV compared to two (0.2%) of the men who had early sexual activity with complete wound healing.
Similar rates of HIV seroconversions were seen in men in the Rakai study who had early sex after incomplete wound healing and those who had early intercourse with complete wound healing (0.6 vs 0.7%).
The investigators note that only a small number of men in two of the studies reported early sexual activity after circumcision, and that there was no apparent increase in the risk of infection with HIV for such men.
However, they caution, “in the immediate postoperative period, it is conceivable that HIV infection risk may be increased through local inflammation during healing or compromised dermal integrity”. Moreover, they emphasise that their statistical analysis suggests that there was a possibility of increased HIV risk if sexual activity was resumed soon after circumcision.
“Circumcision programs should ensure counselling and instruction for wound care, personal wound assessment, and sexual abstinence to limit the possible risk of HIV infection during the early postoperative period”, recommend the investigators.
They also suggest “enhanced counselling should include active involvement of female partners where possible and intense counselling for married men who are more likely to resume sex early”.
Reference:
Mehta SD et al. Does sex in the early period after circumcision increase HIV-seroconversion risk? Pooled analysis of adult male circumcision clinical trials. AIDS 23: 1557-64, 2009.